Examkin

Question

Difficulty: MediumCardiovascular System

An emergency department physician evaluates a 67-year-old man due to four days of escalating dyspnea and nocturnal coughing. The patient reports having to sleep upright in a recliner to avoid respiratory distress. His medical background includes type 2 diabetes, essential hypertension, and osteoarthritis. He recently began taking over-the-counter ibuprofen around the clock for severe knee pain. He smoked one pack of cigarettes daily for 35 years but ceased a decade ago. Temperature is 37.0°C (98.6°F), blood pressure is 158/92 mm Hg, pulse is 112/min, and respirations are 22/min. Pulse oximetry is 92% on room air. Physical examination reveals an anxious patient utilizing accessory respiratory muscles. Jugular venous pressure is elevated at 11 cm H2O. Chest auscultation demonstrates bibasilar dullness to percussion and widespread expiratory wheezes. Cardiac evaluation shows a regular rhythm with a normal S1 and S2, accompanied by a low-frequency sound occurring shortly after S2. Moderate pitting edema is present up to the mid-shins bilaterally. Which of the following is the most appropriate initial pharmacotherapy for this patient?

  1. Intravenous bumetanideAnswer
  2. B
    Nebulized albuterol
  3. C
    Intravenous methylprednisolone
  4. D
    Oral levofloxacin
  5. E
    Subcutaneous enoxaparin

Answer

Intravenous bumetanide
The correct choice is intravenous bumetanide because this patient is presenting with classic signs of acute decompensated heart failure (ADHF). The recent daily use of ibuprofen (an NSAID) likely precipitated fluid retention, leading to pulmonary and systemic venous congestion. Key findings driving this diagnosis include orthopnea, elevated jugular venous pressure, an S3 gallop, and peripheral edema. The wheezing noted on examination represents 'cardiac asthma' caused by peribronchial edema, rather than primary bronchospasm. Intravenous loop diuretics (such as bumetanide or furosemide) are the most appropriate initial therapy to rapidly decrease intravascular volume, lower ventricular filling pressures, and relieve pulmonary edema.

Step-by-Step Solution

1
Analyze the patient's presenting symptoms and history.
The patient has subacute dyspnea, orthopnea (sleeping in a recliner), a history of hypertension, and recent initiation of daily NSAIDs (ibuprofen).
Identifying the timeline and triggers helps narrow the differential diagnosis. NSAIDs can cause sodium and fluid retention, precipitating heart failure.
2
Interpret the physical examination findings.
Findings include elevated JVP, an S3 gallop (low-frequency sound after S2), bibasilar dullness, wheezing, and bilateral pitting edema.
These findings definitively point to left and right ventricular fluid overload. The S3 gallop is highly specific for elevated left ventricular filling pressures.
3
Differentiate between cardiac and pulmonary etiologies of wheezing.
Although the patient has a smoking history and wheezing, the concurrent S3 gallop, orthopnea, and volume overload confirm 'cardiac asthma' due to acute decompensated heart failure, rather than a COPD exacerbation.
Peribronchial edema in heart failure can cause airway narrowing and wheezing that mimics primary pulmonary disease.
4
Determine the most appropriate initial therapy.
The patient requires immediate preload reduction and diuresis with an intravenous loop diuretic.
Loop diuretics (like bumetanide or furosemide) rapidly improve pulmonary congestion and symptoms of acute decompensated heart failure.

Key Concept

Differentiating acute decompensated heart failure (which can present with wheezing known as 'cardiac asthma') from COPD exacerbation, and treating appropriately with intravenous loop diuretics.
Rate this question

Topics

Cardiovascular System

More questions from this topic